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800 Beverly Hanks Centre ♦ PO Box 1109

Hendersonville, NC 28793

(800) 228-3132Fax (828) 692-4717www.morrowinsurance.com

A. GENERAL INFORMATION

Name of Insured (as will appear on policy):__________________________________________________ Doing business as: ______________________________________________________________________ Mailing Address: _________________________________________________________________________ City: _________________________ State: _______________________ Zip: ______________________ Contact Person: _______________________________________ FEIN#: ___________________

Person is: □ Owner □ Promoter □ Agent □ Other: _____________________________

Camp Season Phone: ____________ Off Season Phone: ______________ Fax: ______________________ Name of Agency/Brokerage: _______________________________________________________________ Contact Person: ____________________________ E-Mail Address: _____________________________ Mailing Address: _________________________________________________________________________ City: ______________________ State: ______________________ Zip: ________________________ Phone: ___________________________________ Fax: _______________________________________ Camp Web Site: __________________________________________________________________________

Insured is: □ Corporation □ Partnership □ Joint Venture □ For Profit □ 501 3C Non Profit

□ Other (explain): ___________________________________________________________

Number of year in business: ____________ Number of years under present management: _________ State the location in which the organization is headquartered/chartered: ______________________________ Policy period requested: From: ________________________ To: _________________________________

Has your coverage ever been cancelled or non-renewed? □ Yes □ No

If yes, why: __________________________________________________________________________ Please describe any prior losses over $5,000: __________________________________________________ _______________________________________________________________________________________

B. COVERAGE INFORMATION

ADDITIONAL INSUREDS RELATIONSHIP ADDRESS

Location of camp: _______________________________________________________________________ Location of off-premises office: _____________________________________________________________ Is off-premises office located in a commercial building or residence? Total sq. footage of off-premises office: Any other insured locations: List all other operations of the named insured that are not camp related (ie. Missionary work, school, nursery/day care program, church operations, etc.): _____________________________________________ ______________________________________________________________________________________

Is the camp accredited by: ACA: □ Yes □ No CCCA: □ Yes □ No Other: _____________

Are the camp directs accredited? □ Yes □ No

If yes, by whom? ____________________________________________________________________

CAMP INSURANCE

INFORMATION

FORM

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Type of Camp (check all that apply):

□ Day Camp □ Resident Camp □ Travel Camp □ Sports Camp □ Special Needs □ Adult

Date camp opens: __________________________________ closes: ______________________________ Camper days: A. Average number of campers per day: __________________ B. Number of days per week: x __________________ C. Number of weeks per year: x __________________ Total Number of camper days ( A x B x C ) =__________________

*If more than one camp or more than one location, please attach on additional sheet of paper and list each separately.

Are any camp sessions designed for those with physical or mental handicaps, challenges, or illnesses? □ Yes □ No

If yes, explain: ______________________________________________________________________ ______________________________________________________________________________________ Do you obtain a certificate of insurance from subcontractors, naming your organization as an

additional insured on their policy? □ Yes □ No

Date of last board of health inspection: _______________________________________________________

Do employees, management, or caretakers, etc. live on premises annually? □ Yes □ No

If yes, whom: ______________________________ How many units do they occupy? ______________ If not, explain security/maintenance for premises in the “off-season”: ____________________________ ______________________________________________________________________________________

Are all buildings at the insured premises owned by the named insured? □ Yes □ No

If no, please specify: _________________________________________________________________

Do you have volunteers? □ Yes □ No

If yes, for what position(s)? ____________________________________________________________

Are doctors, nurses, and/or certified medical personnel on the premises during camp? □ Yes □ No

If not, explain medical procedures: ______________________________________________________ Do all doctors, nurses, and/or certified medical personnel/EMTs have their own professional

liability insurance in force with a minimum $500,000 limit? □ Yes □ No

Does camp obtain medical permission slides? (If yes, attach copy) □ Yes □ No

Does camp require details regarding all prescription medicines being used by campers? □ Yes □ No

The nearest hospital or emergency medical facility is _____________ miles away.

Does camp carry primary accident medical and/or sickness insurance? □ Yes □ No

If yes, name of insurer? ______________________ Limit per camper? ______________________

Would you like a quote for excess camper medical insurance? □ Yes □ No

Does camp require an acknowledgement or risk/consent form to be signed by each camper

and their parent(s)/guardian(s)? (If yes, attach copy) □ Yes □ No

Is there an Ansul or similar automatic fire protection system over all cooking surfaces? □ Yes □ No

If yes, what type? ____________________________________________________________________ If no, explain: _______________________________________________________________________

Distance to nearest fire station: _______ (road miles) □ Paid Fire Department □ Volunteer Fire Department

Distance to nearest fire hydrant from the insured premises: _______ (road miles)

Do all sleeping rooms have smoke detectors? □ Yes □ No

Are any buildings sprinklered? □ Yes □ No

If yes, which ones? __________________________________________________________________

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C. CONFERENCE / RENTALS / LEASING □ N/A

Is camp leased to outside entities (e.g. conferences, retreats, reunions, weddings, etc.)?

If yes, are certificates of insurance naming camp as an additional insured required? □ Yes □ No

Are limits of $1,000,000 required? □ Yes □ No

If no, explain: _______________________________________________________________________

Are contracts/agreements signed with these entities? (If yes, attach sample) □ Yes □ No

Gross receipts from leased periods: $______________________________________________________ During leased periods, does camp director/management or any other employees

remain on the premises? □ Yes □ No

If yes, please explain: ________________________________________________________________

Do activities take place during leased period that do not take place during usual camp operations? □ Yes □ No

If yes, please explain: ________________________________________________________________

Do you sell or furnish liquor during leased periods? □ Yes □ No

If yes, please complete the Liquor Liability Application.

D. PERSONNEL

Ratio of counselors to campers during activities: _______________________________________________ Ratio of counselors to campers during non-activity hours: ________________________________________

Are campers always attended by counselors? □ Yes □ No

Minimum age of counselors: _______________________________________________________________

Do you have a Counselor in Training (CIT) or similar program? □ Yes □ No

If yes, what is the minimum ago for the program? ___________________________________________ What is the percentage of counselors who are returning from the previous year? ______________________

Are training classes mandatory for counselors? □ Yes □ No

Describe formal training, certification or previous experience required of counselors: ___________________ ______________________________________________________________________________________

E. TRANSPORTATION

Is camp responsible for campers transportation to and from camp? □ Yes □ No

Does camp allow any employee or volunteer to transport campers in their personal vehicles? □ Yes □ No

If yes, please complete the Employee/Volunteer Transportation Questionnaire.

Does camp hire: □ vans □ buses □ other _________________________

Annual cost to hire vehicles: A. Where the camp must Insure the vehicle $__________________________ (Primary) B. Where the lessor insures the vehicle $__________________________ (Excess) *

* Please be sure to collect a certificate of insurance evidencing automobile liability coverage and naming camp as additional insured.

Minimum age of driers who transport campers? ________________________________________________ Minimum age of drivers not transporting campers? ______________________________________________

Is a fleet safety program in place? □ Yes □ No

If yes, please describe: _______________________________________________________________

Are vehicles ever loaned or given to employees for their use? □ Yes □ No

Who is responsible for maintenance of vehicles? _______________________________________________

Do you own 15-passenger buses or vans? □ Yes □ No

If yes, please describe safety procedures, specifically with regard to top loading and/or trailer pulling: __ ___________________________________________________________________________________

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F. ACTIVITIES

Are any of the following activities provided by the camp? (Additional underwriting information may be required)

YES ACTIVITY YES ACTIVITY YES ACTIVITY

□ Adventure program □ Go-karts 3 □ Skin or scuba diving 5

□ Alpine skiing □ Gymnastics □ Trampolines, # ________6

□ Archery □ Inflatable elements, #____ □ Bungee trampolines, # ________

□ ATVs/dirt bikes 1 □ Mountain boarding □ Tubing

□ Bicycling □ Paintball 4 □ Water skiing

□ Back packing □ Petting Zoo □ Waterslides over 15’ tall, #_____

□ Caving □ Rappelling □ Whitewater canoeing/kayaking/rafting

□ Circus activities □ Rifle ranges, # ________ □ Zip lines, #_______

□ Cross country skiing □ Rock climbing/climbing wall □ Other ____________________

□ Farming □ Rope courses □ Other ____________________

□ Fireworks 2 □ Saddle animals

□ Field sports □ Skateboarding ramps/jumps

1 – ATV/Dirt Bike Questionnaire required 4 – Paintball Supplemental Application required

2 – Fireworks Supplemental required 5 – Diving Questionnaire required

3 – Go-Kart Operations Minimum Underwriting Guidelines required

6 – Trampoline Questionnaire required

Does camp have a safety plan for all activities checked? (If yes, attach copy) □ Yes □ No

Does camp contract with others for program services for any of these activities? □ Yes □ No

If yes, please explain: ________________________________________________________________ __________________________________________________________________________________

If shooting/riflery is provided, are NRA standards met? □ N/A □ Yes □ No

INFLATABLE ELEMENTS □ N/A (ie: moonbounce, water trampoline, iceberg, blob, etc…_

Type of inflatable (official name): ____________________________________________________________ Average number of participants/campers for each inflatable: ______________________________________ Age group for each inflatable: ______________________________________________________________

Are inflatables: □ Owned □ Leased/Rented

Are inflatables: □ Kept on premises □ Taken off premises □ Both

Are all employees/lifeguards trained in the operation rules of the inflatable element usage? □ Yes □ No

Are rules posted for all users? □ Yes □ No

How will the unit(s) be protected from unauthorized use? _________________________________________ ______________________________________________________________________________________ Are there any requirements to enter the inflatable? (removal of shoes, glasses, etc.) _____________________

Are there any restrictions in place for inclement weather? (ie: wind, rain, etc.) □ Yes □ No

If yes, please explain: ________________________________________________________________

Confirm that NO inflatable will be set up outdoors, if wind gusts exceed 20 mph on the day of operation? □ Yes □ No

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SPECIFIC TO WATER BASED INFLATABLE ELEMENTS ONLY □ N/A

Are the element(s) maintained at all times (when in use) in at least 6’ of water? □ Yes □ No

Are the element(s) supervised at a ratio of at least 1 lifeguard to 4 patrons? □ Yes □ No

Will diving off any of the element(s) be permitted? □ Yes □ No

Are lifejackets required? □ Yes □ No

Are the units permanently anchored in the lake/body of water? □ Yes □ No

Will any element(s) be pulled by a motorboat? □ Yes □ No

SADDLE ANIMALS □ N/A

Number owned or leased: ___________________ Used at outside stable: ___________________

If subcontracted, are certificates of insurance naming camp as additional insured required? □ Yes □ No

Are limits of $1,000,000 required? If no, explain: _______________________________________________________________________

Is safety equipment (e.g. helmets, heeled boots, long pants, etc.) required? □ Yes □ No

Are horses available for riding during leased periods? □ Yes □ No

If yes, explain: ______________________________________________________________________

Are instructors CHA certified? □ Yes □ No

Are all saddle animals vaccinated? □ Yes □ No

PETTING ZOO □ N/A

What kind of animals? ____________________________________________________________________

Are all animals properly vaccinated? □ Yes □ No

Is there a hand washing station? □ Yes □ No

If no, explain: ___________________________________________________________________________

WATERSLIDE (over 15 feet in height) □ N/A

Are there attendants at the top and bottom of the slide(s) to monitor and space participants? □ Yes □ No

What is the height of each slide? ____________________________________________________________ What is the length of each slide? ____________________________________________________________

Is the slide maintained by a qualified maintenance person? □ Yes □ No

Is head first sliding allowed? □ Yes □ No

Are there signs posted to instruct patrons on proper behavior and riding techniques? □ Yes □ No

If yes, where: _______________________________________________________________________

IF CAMP UTILIZES A POOL: □ N/A IF CAMP UTILIZES A LAKE/POND/RIVER: □ N/A

Total number of pools: ________________________ Is it open to members of the public? □ Yes □ No

Is it open to members of the public? □ Yes □ No Maximum depth of swimming area: ______________

Maximum depth of swimming area: ______________ Is swim area roped off? □ Yes □ No

Is it fenced? □ Yes □ No Height: ____________ Is signage posted clearly stating the depth of water Are depth markings clearly visible

in and around the pool? □ Yes □ No and the rules for the lake/pond? □ Yes □ No

Number of diving boards: _____________________ Number of diving boards: _______ Height: ________ Height of diving boards: ______________________

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(CONT’D)

IF CAMP UTILIZES A POOL: □ N/A

(CONT’D)

IF CAMP UTILIZES A LAKE/POND/RIVER: □ N/A

Depth of water at diving board entry: ____________ Depth or water at diving board entry: ____________

Is a lifeguard provided? □ Yes □ No Is a lifeguard provided? □ Yes □ No

If yes, ratio of swimmers to lifeguards: _________ If yes, ratio of swimmers to lifeguards: _________

Are lifeguards certified? Are lifeguards certified? If yes, by whom? ________________________ If yes, by whom? ________________________

Are rules posted at the pool area? □ Yes □ No Rescue vehicle available? □ Yes □ No

Any nighttime swimming allowed? □ Yes □ No Any nighttime swimming allowed? □ Yes □ No

If yes, is pool lighted? □ Yes □ No If yes, describe lighting: ___________________ Total number of lakes/ponds/rivers: _____________ Total number of lakes/ponds/rivers: _____________

Are there other bodies of water on premises (not just those normally utilized) and are there depth markings,

signage, barriers, and/or general supervision utilized to prevent unauthorized use? □ Yes □ No

Is/Are you pool(s)/spa(s) compliant with the Virginia Graeme Baker Pool & Spa Safety Act? □ Yes □ No

TUBING, RAFTING, CANOEING, KAYAKING, SAILING, OR BOATING: □ N/A

If your camp provides any of the following activities, please list the number of boats in each category below:

___________Canoes _________Kayaks __________Motorboats under 76 HP ___________Rowboats _________Paddleboats __________Motorboats over 76 HP ___________Sailboats _________Personal Watercraft __________Are any boats over 21’ in length?

(e.g. Jet Skis, Waverunners, etc.)

Explain uses for powered boats and personal watercraft: _________________________________________ ______________________________________________________________________________________

Are lifejackets, etc. required to be worn by each participant during all water activities? □ Yes □ No

Are campers always accompanied by qualified counselors? □ Yes □ No

Are campers ever permitted to operate motorized boats? □ Yes □ No

Are lifeguards always in attendance during these activities? □ Yes □ No

Is area restricted to campers only during these activities? □ Yes □ No

Completely describe any “white water” exposures, including the experiences of counselors: __________ _______________________________________________________________ _______________________________________________________________

GYMNASTICS: □ N/A

Floor exercises only? □ Yes □ No

List all apparatus used: ___________________________________________________________________ ______________________________________________________________________________________

Is counselor/instructor a certified USGA gymnastics instructor? □ Yes □ No

If so, do you require a copy of the certificate? □ Yes □ No

If not, explain the instructor’s qualifications: ___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

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ROPES COURSES/ZIP LINES: □ N/A

Completely describe the area and type of high/low elements: _____________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Is the course inspected annually by a certified independent consultant (ACCT/PVM: AEE: PRCA)? □ Yes □ No

If yes, by whom? ____________________________________________________________________ Describe staff training (by whom, how often, confirmation that all ropes course staff are included in the training): _______________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

SKATEBOARDING/SKATEPARK: □ N/A

Is safety equipment (helmet, knee pads, elbow pads, etc.) required? □ Yes □ No

If elements/obstacles are present (ramps, rails, boxes, banks, quarterpipes, etc.), please describe and indicate size of each._____________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ If halfpipe, indicate height: _____________________________________________________________ How is skatepark protected from unauthorized usage? ___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

CLIMBING WALLS/ROCK CLIMBING/RAPPELLING: □ N/A

Number of indoor climbing walls: Stationary/permanent: _______ Moveable: _______ Number of outdoor climbing walls: Stationary/permanent: _______ Moveable: _______ List equipment used: _____________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ List counselors/instructors qualifications: _____________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

CAVING: □ N/A

Cave type: □ Vertical □ Horizontal

If vertical, how deep? _____________________________________________________________________

Has the cave been approved for safety? □ Yes □ No

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G. SEXUAL ABUSE/MOLESTATION QUESTIONNAIRE

Would you like a quote for sexual abuse and molestation coverage (if eligible)? □ Yes □ No

Do you discuss the following at staff orientation: child/sexual abuse, how to recognize the

signs, and what to do if a camper or member reports someone has molested him/her? □ Yes □ No

Do you have a plan of supervision that monitors staff in day to day living relationships

with campers? □ Yes □ No

Does your staff (paid/volunteer) employment application include questions about whether the

individual has ever been convicted for any crime including sex related or child abuse related offenses? □ Yes □ No

If yes, please attach copy. If application contains this type of questions, and applicant checks “yes” to prior convictions,

are they refused a position of employment? □ Yes □ No

Does your state permit you to do criminal background investigations on staff members? □ Yes □ No

a) If yes, do you request and receive such background investigations on all staff members? □ Yes □ No

b) If yes, who provides service? ___________________________________________________________

Have you ever had an incident which resulted in an allegation of sexual abuse at your camp? □ Yes □ No

a) Was a claim made against your camp? □ Yes □ No

If yes, please provide details of the claim/incident:_______________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

b) How much money was paid as damages to the victim? ____________________________________ c) What has been done to prevent such occurrences from happening in the future? ________________

______________________________________________________________________________________ ______________________________________________________________________________________ If you have volunteers, are the answers to the questions above the same?

□ Yes

□ Not applicable, we have no volunteers.

□ No. Please explain: _____________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

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PLEASE BE SURE TO ATTACH THE FOLLOWING WITH THE APPLICATION

□ A. Camp brochure/literature defining

activities (if no camp website).

□ F. Brief resume of camp management

personnel (required when camp ownership, operation or management has changed within the past 12 months).

□ K. Copy of contract or lease

agreement used for lessors of premises, if applicable.

□ B. Schedule of events/activities or

calendar of camp season (if no camp website).

□ G. Copy of staff application and, when

applicable, background check consent form (if not on camp website)

□ L. Copy of certificate of insurance from

transportation company, naming camp as additional insured is required if Excess Hired Auto coverage is provided.

□ C. Company copies of loss history for

last five (5) years.

□ H. Copy of camper registration form (if

not on camp website)

□ M. Copy of most recent ropes

course/zip line inspection.

□ D. Diagram, map or photos of camp

including any natural or man-made hazards.

□ I. Copy of camp acknowledgment of

risk and consent form for campers (if not on camp website).

□ N. Auto schedule must include seating

capacity for each scheduled van or bus.

□ E. Copy of operations manual

(including safety, medical and emergency procedures) and employee/staff training manual.

□ J. Copy of medical permission slip for

campers (if not on camp website).

□ O. Appropriate Questionnaire or

Supplemental Application when the insured has any of the following: go kart; fireworks; paintball; trampoline; scuba/skin diving.

I understand that the insurance company in determining whether to provide a quotation for insurance coverage will rely on the information contained in the application and all other information being submitted. I hereby warrant, represent, and confirm that, to the best of my knowledge, all information provided is complete, true, and correct. _________________________________________ _________________________________________ Applicant’s Signature Producer’s Signature (if applicable) _________________________________________ _________________________________________ Applicant’s Name Producer’s Name (if applicable) _________________________________________ _________________________________________ Date (MM/DD/YYYY) Date (MM/DD/YYYY)

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Camp Insurance Application

WORKERS' COMPENSATION INSURANCE APPLICATION

Name of Business: _______________________________________________________________________

Mailing Address: ________________________________________________________________________

Contact Person: Phone Number: ____________________________________________________________

FEIN#: ________________________________________________________________________________

Legal Status of Business: __________________________________________________________________

□ Corporation □ 5013C □ Sole Prop. □ Partnership □ Other__________________________

Primary Work Location Address: ___________________________________________________________

Proposed Effective Date: _______________________ Experience Modifier: _______________________

Employer’s Liability Limits:

$100,000 / $500,000 / $100,000 (Statutory)

$500,000 / $500,000 / $500,000

$1,000,000 / $1,000,000 / $1,000,000

State(s) from which you operate: ____________________________________________________________

_______________________________________________________________________________________

Classifications Estimated Annual Payroll

9015 Camp Operations ________________________

8810 Clerical ________________________

8809 Executive Officers ________________________

8742 Outside Sales ________________________

Other: _____________________ ________________________

Is a formal safety program in place? □ Yes □ No

Claims History (past 5 years): Request 3 or 5 year loss history from current agent and attach.

Signature Date

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Camp Insurance Application

COMMERCIAL AUTO INSURANCE APPLICATION

Name of Insured (as will appear on policy): ___________________________________________________

Policy period requested: From_____________________________ To_____________________________

Commercial Auto Coverage Information

* Please complete the attached Drivers Schedule for each possible driver (page 10).

* Please complete the attached Vehicle Schedule for all owned or leased vehicles (page 11).

Desired Limits for Liability and Uninsured/Underinsured Motorists: (check one)

□ $500,000 CSL □ $1,000,000 CSL

Desired Limit for Personal Injury Protection or Medical Payments: (check one)

□ PIP or □ Med Pay □ $2,500 □ $5,000 □ $10,000

List ALL Auto Claims for the Past 3 Years: ___________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Is Hired and Non-Owned Liability coverage desired?__________________________________________

It is understood and agreed that no insurance is in effect until this coverage request is accepted by the

company or companies in writing.

Signature: _________________________________________ Date: ______________________________

Title: _________________________________________________________________________________

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or a request for coverage containing false, incomplete,

or misleading information is guilt of a felony of the their degree.

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Camp Insurance Application

LIST OF DRIVERS

Name State Drivers License # Date Of Birth

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Camp Insurance Application

VEHICLE SCHEDULE

Item Year Make & Model Vin # Cost Liab PIP U/M Comp Ded.

Coll Ded.

EXAMPLE

1 1998 CHEV ½ TON PICKUP 1GM4X63897214 21,000 X X X 500 500

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Camp Insurance Application

PROPERTY INSURANCE APPLICATION

Name of Insured (as will appear on policy): ___________________________________________________

Policy period requested: From_____________________________ To_____________________________

Property Coverage Information

Please complete the attached Schedule (page 13) for each location described below:

Physical Location #1 Address:______________________________________________________________

Physical Location #2 Address:______________________________________________________________

Check coverages to apply:

Deductible: □ $250 □ $500 □ $1,000 □ $2.500

Cause of Loss: □ Basic Form □ Broad Form □ Special Form

Buildings &/or Contents: □ Blanket □ Scheduled

Business Income/Extra Expense Limit: _____________________________________________

Mortgagee, Loss Payee, or Additional Insured: _________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

It is understood and agreed that no insurance is in effect until this coverage request is accepted by the

company or companies in writing.

Signature: _________________________________________ Date: ______________________________

Title: _________________________________________________________________________________

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or a request for coverage containing false, incomplete,

or misleading information is guilt of a felony of the their degree.

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Camp Insurance Application

PROPERTY SCHEDULE

Loc #

Bldg #

Description – including name, address, & occupancy

Year Built

Stories Construction Sq. Ft. Bldg Limit.

Contents Limit

EXAMPLE

1 1 Camp Office, 100 Main St 1995 1 Frame 2500 112,000 10,000

1 2 Dining Hall, 100 Main St. 1990 1 Brick 3500 400,000 50,000

Types of Construction:

(F) Frame, (BV) Brick Veneer, (B) Brick, (ICM), (SFR) Semi Fire Resistive, (FR) Fire Resistive